Coronial
WAother

Inquest into the Death of Bropho, Robert Charles

Deceased

Bropho, Robert Charles

Demographics

81y, male

Date of death

2011-10-24

Finding date

2013

Cause of death

Acute myocardial infarction in association with coronary artery atherosclerosis

AI-generated summary

Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, died from acute myocardial infarction. The coroner found the quality of medical care in custody was high, with appropriate cardiac and diabetes care plans, regular hospital consultations (40 visits to Royal Perth Hospital), and competent nursing. However, systemic failures occurred: family were not notified when the deceased was transferred to hospital emergently, and Phase 2 terminal illness classification was not disclosed to the prisoner or family until the royal prerogative consultation process. The coroner found the deceased's allegations of mistreatment largely unsupported by contemporaneous medical records. Medical management was appropriate for his terminal condition; little could have been done to prevent death given advanced coronary atherosclerosis.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologygeneral medicinenephrologycorrectional healthendocrinologyophthalmologypathology

Error types

communicationsystem

Drugs involved

insulinnitrolingual sprayanalgesicscardiac medications

Clinical conditions

acute myocardial infarctioncoronary artery atherosclerosisinsulin-dependent diabetes mellitushypertensionchronic renal failuresevere ischaemic heart diseaseanginacardiac failurehypothyroidismdepression

Procedures

coronary angiogramcardiac monitoringcardiac resuscitationcataract surgery

Contributing factors

  • Severe coronary artery atherosclerosis with widespread stenosis
  • Longstanding insulin-dependent diabetes mellitus
  • Hypertension
  • Chronic renal failure
  • Advanced age
  • Systemic failure to notify next of kin of emergency hospital transfer

Coroner's recommendations

  1. The Department of Corrective Services and WA Police should implement a procedure to ensure families of deceased prisoners are notified without delay notwithstanding that a person nominated as next of kin is not able to be contacted, including having alternative contact persons.
  2. The Department of Corrective Services should consider amending Policy Directive 8 to require that a person classified as having Phase 1 or Phase 2 terminal illness be notified of the classification and its ramifications as soon as practicable after classification occurs.
  3. The Department should consider reviewing the procedure under Policy Directive 8 to reduce instances where restraints are applied in clearly inappropriate situations, such as when a seriously ill prisoner is being transferred to hospital.
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